In the early Monday morning hours of April 16, 2007, 23-year-old Seung-Hui Cho went on what purports to be the second bloodiest school massacre in the history of this nation, and topping the most well-known school shooter, 25-year-old Charles Whitman. The first involved 55-year-old Andrew Philip Kehoe's May 18, 1927, bombing of Michigan's Bath elementary school that left 45 dead and 58 wounded.[1] Kehoe may have also had something to do with the death of his stepmother, who became engulfed in flames when the family stove exploded. A decade before his stepmother's untimely death, then 30-year-old Kehoe reportedly incurred a traumatic brain injury that left his personality forever changed.[2] Is this what precipitated Kehoe's final descent into violence?

On Monday, August 1, 1966, 25-year-old Charles Joseph Whitman ascended the steps to an observation deck atop the University of Texas bell-tower in Austin, Texas. From there, he opened fire. Nearly three hours and 47 victims later Austin law enforcement and deputized citizens breached the tower, shooting and killing Whitman.[3] A "Post-mortem autopsy of his brain revealed a glioblastoma multiforme tumor the size of a walnut, erupting from beneath the thalamus, impacting the hypothalamus, extending into the temporal lobe and compressing the amygdaloid nucleus"[4][5] The pressure caused by the tumor ensured Whitman's amygdala was perpetually activated, thus rendering him unable to regulate aggressive impulses.[6]

As with the self-styled "Trenchcoat Mafia," Dylan Klebold[7] and Eric Harris[8] whose April 20, 1999 shooting spree left 13 dead and an additional 23 wounded,[9] Cho's case gained immediate national attention. Unlike the others that went before him however, Cho was reportedly not a target of bullying nor did he have a brain tumor. Nor does he appear to meet the criteria for Robert Hare's psychopath. It goes without saying—though some tenaciously cling to their belief—the long since debunked video game theory was not a factor either. So, what was it, exactly, that compelled Cho to go on his Monday morning rampage? More importantly, what if anything, can be done to protect our society against future tragedies such as this?

While Cho's 'so-called' manifesto lends few clues, early reports had already begun painting a disturbing picture of a severely mentally disturbed individual and a systemic faux pas. The recently released findings by the committee that was empaneled by Virginia Governor Timothy M. Kaine, on Thursday, April 19, 2007, reveal just how bad things were.[10] Among other issues, that included but were not limited to privacy concerns (HIPAA and FERPA), emergency response and gun control, the report reflected that, "Records of Cho's minimal treatment at Virginia Tech's Cook Counseling Center are missing."[11] This is disturbing, to say the least. In a normal situation, it could be a reflection of nothing more than sloppy record keeping. In the context of this case however, the tragic yet arguably preventable case of Tatiana Tarasoff comes to mind.

In the fall of 1969, Prosenjit Poddar, a UC Berkeley student, became fixated on a female student, Tatiana Tarasoff. During a clinical session with licensed psychologist, Dr. Lawrence Moore, he indicated that he planned to kill Ms. Tarasoff. Moore contacted campus police, who briefly detained Poddar. Moore's supervisor, Dr. Harvey Powelson, directed that no further action be taken. Two months later, on October 27, 1969, Poddar shot and killed Ms. Tarasoff. Her parents later brought a lawsuit against the Regents of the University of California for failing to warn their daughter of the imminent danger.[12] This precedent setting case became known as the Tarasoff ruling and as a result, the "Duty to Warn" was codified into California Civil Code §43.92. As with the "Duty to Report," this law is one of the exceptions that overrides the confidentiality clause. Other states have since enacted their own version of Tarasoff.